CAHPS American Indian Survey

CAHPS® American Indian Survey

Version: Adult Language: English

For assistance with this survey, please contact the CAHPS Help Line at 800-492-9261 or [email protected].

File name: american-indian-eng-851.docx Last updated: March 4, 2009

mailto:[email protected]

CAHPS American Indian Survey

Instructions for Front Cover

• Replace the cover of this document with your own front cover. Include a user-friendly title and your own logo.

• Include this text regarding the confidentiality of survey responses: Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential. You may notice a number on the cover of the survey. This number is used only to let us know if you returned your survey so we don’t have to send you reminders. Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the health care you get. What To Do When You’re Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to [INSERT VENDOR ADDRESS]. If you want to know more about this study, please call XXX-XXX-XXXX.

Instructions for Format of Questionnaire

Proper formatting of a questionnaire improves response rates, the ease of completion, and the accuracy of responses. The CAHPS team’s recommendations include the following:

• If feasible, insert blank pages as needed so that the survey instructions (see next page) and the first page of questions start on the right-hand side of the questionnaire booklet.

• Maximize readability by using two columns, serif fonts for the questions, and ample white space.

• Number the pages of your document, but remove the headers and footers inserted to help sponsors and vendors distinguish among questionnaire versions.


Survey Instructions Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes → If Yes, go to #1 on page 1 No


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Your Provider

1. According to our records, you have visited a [NAME OF PROVIDER] clinic in the last 12 months. Which clinic or clinics did you visit to get care for yourself in the last 12 months? Mark one or more.

1 [CLINIC 1] 3 [CLINIC 2] 4 [CLINIC 3] 5 [CLINIC 4] 6 [CLINIC 5] 7 Another clinic Please print: _______________________ __________________________________

2. Which [NAME OF PROVIDER] clinic did you visit most often in the last 12 months to get care for yourself?


Getting Care Quickly

The next questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits. Answer only for the care you got from [NAME OF PROVIDER].

3. In the last 12 months, did you call or go to a [NAME OF PROVIDER] clinic to get an appointment for an illness, injury, or condition that needed care right away?

1 Yes 2 No → If No, go to #5

4. In the last 12 months, when you called or went to a [NAME OF PROVIDER] clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed it?

1 Never 2 Sometimes 3 Usually 4 Always

5. In the last 12 months, when you called or went to a [NAME OF PROVIDER] clinic to get an appointment for care you needed right away, how long did you usually have to wait between trying to get an appointment and actually seeing a doctor or other health professional?

1 Same day 2 1 day 3 2 to 3 days 4 4 to 7 days 5 8 to 14 days 6 15 days or longer


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6. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a [NAME OF PROVIDER] clinic?


7. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a [NAME OF PROVIDER] clinic as soon as you thought you needed it?


After Hours Care

8. In the last 12 months, did you call a [NAME OF PROVIDER] clinic for medical help or advice after regular office hours?


9. In the last 12 months, when you called a [NAME OF PROVIDER] clinic after regular office hours, how often did you get the medical help or advice you needed?



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Wait Time

10. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did your visit with the person you went to see start within 15 minutes of your appointment?


11. In the last 12 months, after you checked in for your appointment at a [NAME OF PROVIDER] clinic, were you kept informed about how long you would need to wait for the person you went to see?

1 Definitely yes 2 Somewhat yes 3 Somewhat no 4 Definitely no

Your Primary Doctor or Nurse

12. A primary doctor or nurse is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a primary doctor or nurse?

1 Yes 2 No → If No, go to #29 on page 6

13. How long has this person been your primary doctor or nurse?

1 Less than 6 months 2 At least 6 months but less than 1 year 3 At least 1 year but less than 3 years 4 At least 3 years but less than 5 years 5 5 years or more

14. Which one of the following clinics do you go to when you see your primary doctor or nurse?



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15. In the last 12 months, how many times did you visit your primary doctor or nurse to get care for yourself?

None → If None, go to #29 on page 6

1 time 2 3 4 5 to 9 10 or more times

16. In the last 12 months, did your primary doctor or nurse suggest that you see a specialist for a health problem?


17. In the last 12 months, how often did your primary doctor or nurse seem informed and up-to-date about the care you got from specialists?


18. In the last 12 months, did you and your primary doctor or nurse talk about specific things you could do to prevent illness?

1 Yes 2 No

19. In the last 12 months, did you want your primary doctor or nurse’s help in making changes in your habits or lifestyle to prevent illness?

1 Yes 2 No

20. In the last 12 months, did your primary doctor or nurse encourage you to talk about your health concerns, including those that might be embarrassing?

1 Yes 2 No

21. In the last 12 months, did you and your primary doctor or nurse talk about how to maintain a healthy diet and healthy eating habits?

1 Yes 2 No

22. In the last 12 months, did you and your primary doctor or nurse talk about the exercise or physical activity you get?

1 Yes 2 No

23. In the last 12 months, did you and your primary doctor or nurse talk about things in your life that worry you or cause you stress?

1 Yes 2 No


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24. Do you now smoke cigarettes or use other tobacco products every day, some days, or not at all?

1 Every day 2 Some days 3 Not at all → If Not at all, go to #28 4 Don’t know → If Don’t know, go to

#28

25. In the last 12 months, were you advised to quit smoking or stop using tobacco by your primary doctor or nurse?

1 Yes 2 No

26. Medication to help you quit smoking can include nicotine gum, patch, nasal spray, inhaler, or prescription medication. In the last 12 months, did your primary doctor or nurse recommend or discuss medication to help you quit smoking or using tobacco?

1 Yes 2 No

27. In the last 12 months, did your primary doctor or nurse recommend or discuss methods or strategies other than medication to help you quit smoking or using tobacco?

1 Yes 2 No

28. Using any number from 0 to 10, where 0 is the worst primary doctor or nurse possible and 10 is the best primary doctor or nurse possible, what number would you use to rate your primary doctor or nurse?

0 Worst primary doctor or nurse possible

1 2 3 4 5 6 7 8 9 10 Best primary doctor or nurse

possible


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Getting Needed Care

29. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you try to make any appointments to see a specialist?


30. In the last 12 months, how often was it easy to get appointments with specialists?


31. How many specialists have you seen in the last 12 months?

None → If None, go to #34 1 specialist 2 3 4 5 to 9 specialists

32. In the last 12 months, how often did the specialists you saw seem to know the important information about your medical history?


33. Which of the following clinics did you visit to see a specialist in the last 12 months? Mark one or more.


34. In the last 12 months, did you try to get any care, tests or treatment?


35. In the last 12 months, how often was it easy to get the care, tests, or treatment you thought you needed?



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Communication

36. In the last 12 months, how often did your primary doctor or nurse explain things in a way that was easy to understand?


37. In the last 12 months, how often did your primary doctor or nurse listen carefully to you?


38. In the last 12 months, how often did your primary doctor or nurse show respect for what you had to say?


39. In the last 12 months, how often did your primary doctor or nurse spend enough time with you?


Communication About Prescription Medications

40. In the last 12 months, did you get any prescriptions for medicines that you had not taken before?


41. In the last 12 months, how often did your primary doctor or nurse explain the purpose of these medicines in a way that was easy to understand?



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Communication About Illnesses or Health Conditions

42. In the last 12 months, did you see a doctor or other health professional for an illness or health condition that was bothering you?


43. In the last 12 months, how often did a doctor or other health professional explain in a way that was easy to understand what to do if your illness or health condition got worse or came back?


Communication About Test Results

44. In the last 12 months, did any health professional (including a doctor) send you for a blood test, x-ray, or other test?


45. In the last 12 months, when a health professional sent you for a blood test, x-ray, or other test, how often did someone from the health professional’s office follow up to give you the test results?


46. In the last 12 months, how often did doctors or other health professionals explain test results in a way that was easy to understand?



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Making Decisions About Your Care

47. Choices for your treatment or health care can include choices about medicine, surgery, or other treatment. In the last 12 months, did a doctor or other health professional recommend a treatment for a health problem that was bothering you?

1 Yes 2 No

48. In the last 12 months, did a doctor or other health professional tell you there was more than one choice for your treatment or health care?


49. In the last 12 months, did a doctor or other health professional talk with you about the pros and cons of each choice for your treatment or health care?


50. In the last 12 months, when there was more than one choice for your treatment or health care, did a doctor or other health professional ask which choice you thought was best for you?


Clerks and Receptionists at Your [NAME OF PROVIDER] Clinic

51. In the last 12 months, how often were clerks and receptionists at your [NAME OF PROVIDER] clinic as helpful as you thought they should be?


52. In the last 12 months, how often did clerks and receptionists at your [NAME OF PROVIDER] clinic treat you with courtesy and respect?



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Prescriptions

53. In the last 12 months, did you need any new prescription medicine or need to refill a prescription?


54. In the last 12 months, was it easy to get prescription medicine you needed through your [NAME OF PROVIDER] clinic?


55. In the last 12 months, how often did you get the prescription medicine you needed through your [NAME OF PROVIDER] clinic?


Overall Rating Of Clinic

56. For this next question, please think about the [NAME OF PROVIDER] clinic you visited most often in the last 12 months. Using any number from 0 to 10 where 0 is the worst clinic possible and 10 is the best clinic possible, what number would you use to rate the clinic?

0 Worst possible clinic 1 2 3 4 5 6 7 8 9 10 Best possible clinic


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Discrimination

57. In the last 12 months, have you ever felt that a health professional you saw judged you unfairly or treated you with disrespect for any reason?


58. In the last 12 months, did you feel that a health professional you saw judged you unfairly or treated you with disrespect because of your tribal affiliation?

1 Yes 2 No

59. Blood quantum level refers to the level of tribal blood required for membership in an Indian tribe. In the last 12 months, did you feel that a health professional you saw judged you unfairly or treated you with disrespect because of your blood quantum level?

1 Yes 2 No 3 I’m not sure

Look for Information

60. In the last 12 months, did you look for information in written materials or on the Internet about how to get care from a [NAME OF PROVIDER] clinic or hospital?


61. In the last 12 months, how often did the written materials or the Internet provide the information you wanted on how to get care from a [NAME OF PROVIDER] clinic or hospital?


62. Do you know if [NAME OF PROVIDER] has a website?


63. In the last 12 months, did you visit the [NAME OF PROVIDER] website to get information or help about the hospital or clinics?


64. In the last 12 months, how often did the [NAME OF PROVIDER] website provide the information or help you wanted about the hospitals or clinics?



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About You

There are only a few questions left.

65. In general, how would you rate your overall health?

1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

66. In general, how would you rate your overall mental or emotional health?

1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

67. In the past 12 months, have you seen a doctor or other health professional three or more times for the same condition or problem?


68. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy.

1 Yes 2 No

69. Do you now need or take medicine prescribed by a doctor? Do not include birth control.


70. Is this to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

1 Yes 2 No

71. What is your age? 1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 or older

72. Are you male or female? 1 Male 2 Female

73. What is the highest grade or level of school that you have completed?

1 No formal education 2 5th grade or less 3 6th, 7th or 8th grade 4 Some high school, but did not

graduate 5 High school graduate or GED 6 Some college or 2-year degree 7 4-year college graduate 8 More than 4-year college degree


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74. What is your race? Please mark one or more.

1 American Indian or Alaska Native Please print your tribal affiliation:

______________________________ 2 White 3 Asian 4 Black or African-American 5 Native Hawaiian or other Pacific

Islander 6 Other Please print: _______________________ __________________________________

75. What language do you mainly speak at home?

1 English 2 [NATIVE LANGUAGE] 8 Some other language Please print: _______________________ __________________________________

76. Did someone help you complete this survey?

1 Yes 2 No → Thank you.

Please return the completed survey in the postage-paid envelope.

77. How did that person help you? Mark one or more.

1 Read the questions to me 2 Wrote down the answers I gave 3 Answered the questions for me 4 Translated the questions into my

language 5 Helped in some other way

Thank you.

Please return the completed survey in the postage-paid envelope.

Documents

CAHPS American Indian Survey